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Marijuana Contributes to Psychotic Illness - Rey

Marijuana Contributes to Psychotic Illness - Rey

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Published by PRMurphy
Cannabis abuse is not benign, especially in adolescents. Joseph M. Rey, MD, PhD
Honorary professor, department of psychological medicine, University of Sydney, Australia. Evidence grows that marijuana use can cause acute psychosis, bring forward in time a first schizophrenia episode, and worsen the prognosis of patients with psychotic disorders.
Cannabis abuse is not benign, especially in adolescents. Joseph M. Rey, MD, PhD
Honorary professor, department of psychological medicine, University of Sydney, Australia. Evidence grows that marijuana use can cause acute psychosis, bring forward in time a first schizophrenia episode, and worsen the prognosis of patients with psychotic disorders.

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Published by: PRMurphy on Jan 15, 2011
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04/27/2012

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Does marijuana contribute to psychoticillness?
Cannabis abuse is not benign, especially in adolescents.
Joseph M. Rey, MD, PhD 
Honorary professor, department of psychological medicine, University of Sydney, Australia Evidence grows that marijuana use can cause acute psychosis, bring forward in time a first schizophrenia episode, and worsen the prognosis of patients with psychotic disorders.
 
Roger, age 16, had been smoking marijuana on and off for about 2 years. His parents knew but believed this was a stage and not dangerous; they had tried marijuana in their youth without harm. Roger’s smoking had increased to several joints daily since he started a relationship with an older girl, who shared and encouraged his habit.
 
His parents became worried when Roger began making unusual comments, saying that food did not taste “right” and he thought someone was poisoning him. They brought Roger for psychiatric consultation at the recommendation of their family physician.
 
History and examination revealed that Roger had experienced vague persecutory ideas for several weeks but no systematized delusions or hallucinations. I told Roger and his parents he probably had a drug-induced psychosis and that symptoms would likely disappear without recurrence if he stopped using marijuana. At 2-weeks’ follow-up, he described no more psychotic experiences and said he now realized the danger for him of smoking marijuana. A review 1 month later showed Roger was doing well, and I discharged him after reinforcing the importance of abstinence. But his case didn’t end there.
 
Two years later, I received a request for information about Roger’s episode from an acute inpatient facility. Roger had been admitted after an incident at the local mall in which he screamed at people and accused bystanders of trying to harm him. Despite using marijuana only occasionally, his behavior had been deteriorating and was becoming increasingly bizarre. The attending psychiatrist believed Roger had schizophrenia.
 Clinicians regularly deal with patients such as Roger who suffer from a psychotic disorder and use marijuana. This is hardly surprisingbecause marijuana is the most widely used illicit drug. In 2006, 5% of 12th graders in the United States reported using marijuana dailyduring the previous month, and 42% had tried it at least once.
1
 Is psychotic patients’ use of marijuana a coincidence? Self-medication? Or could cannabis cause psychotic illness? This debate elicitsstrong views among community and professional groups. To help you provide up-to-date advice to patients and families, this review:
 
describes the growing body of evidence on the mental health consequences of marijuana use
 
seeks to help you detect and deal with the effects of marijuana use in clinical practice.
MARIJUANA AND PSYCHOSIS
Although the neurobiologic association is unclear (Box 1),
2
-
4
up to 15% of users report psychotic phenomena after consuming marijuana.
5
 Naturalistic and experimental studies have confirmed that marijuana can induce short-lived psychotic experiences.In two parallel trials, 22 healthy individuals
6
and 13 stable, antipsychotic-treated schizophrenia patients
7
were given 2.5 mg and 5 mgintravenously of delta-9-tetrahydrocannabinol (delta-9-THC)—the primary psychoactive constituent of marijuana. Both groups developeddose-related, transient, schizophrenia-like symptoms and altered perceptions:
 
Healthy volunteers showed the full range of psychotic symptoms. One individual said, “I thought you were giving me THCthrough the blood pressure machine and the sheets.”
2
 
 
Schizophrenia patients tended to report increases in the symptoms of their specific conditions. Those with paranoidillnesses, for example, reported an escalation in persecutory ideas.Transient psychotic phenomena are not equivalent to a psychotic illness, however. To meet diagnostic criteria for a psychotic disorder,symptoms must be persistent and impair psychosocial functioning.
MARIJUANA ANDPSYCHOSIS
 
WHO IS AT RISK?
 
IMPLICATIONS FORTREATMENT
 
IMPLICATIONS FORPREVENTION
 
 
Early reports.
Anecdotal clinical reports that marijuana use could cause psychosis emerged in the 1960s but were largely ignored. Manyclinicians assumed that psychotic individuals used marijuana to relieve troubling symptoms (self-medication).A 15-year, longitudinal study examined the incidence of schizophrenia in >50,000 Swedish conscripts and concluded that marijuana useduring adolescence increased the risk of schizophrenia.
8
Skeptics questioned the validity of the diagnosis and the etiologic role of other drugs in this study and suggested that prodromal symptoms might have led to marijuana use, rather than marijuana triggering thepsychosis.
Recent evidence.
Better-designed studies have shown that marijuana use increases the risk of psychosis later in life.Adolescents who used marijuana by age 15 were more likely to develop a schizophreniform disorder by age 26 than nonusers, according todata from 759 New Zealanders who took part in a prospective, longitudinal, general population study. Marijuana use by age 15 wasassociated with a higher risk than later use (by age 18).
9
 A 3-year, longitudinal, population-based study from the Netherlands found marijuana use associated with increased risk of psychosis in4,045 previously psychosis-free individuals. More than 50% of psychosis diagnoses could be attributed to marijuana use.
10
 Data from the 21-year longitudinal Christchurch Health and Development Study in New Zealand showed elevated rates of psychoticsymptoms in young people with cannabis dependence at ages 18 and 21. The associations remained even after adjustments were madefor previous psychotic symptoms and other confounding factors.
11
 Follow-up analysis of data from the Swedish military conscripts study
8
showed that the use of other psychoactive drugs or prodromal casesin the cohort did not explain the association between self-reported marijuana use and hospital admissions for schizophrenia and other psychoses.
12
 Researchers in Israel cross-linked a cohort of 9,724 youths aged 16 to 17 screened by the Israeli Draft Board with a national registry of psychiatric hospital admissions for schizophrenia in the following 4 to 15 years. Self-reported drug abuse (mostly marijuana) was higher inadolescents who were later hospitalized for schizophrenia (12.4%) than in those not hospitalized (5.9%).
13
 
Summary.
A review of these 5 studies concluded that evidence supports the hypothesis that marijuana use acts as a risk factor inschizophrenia onset.
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Although marijuana use is not a “necessary” causal factor in psychotic illness—most users do not develop thedisorder, and many persons with schizophrenia do not use marijuana—strong evidence indicates that it is one of many factors that cancause a psychotic illness (Box 2).
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-
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WHO IS AT RISK?
Can marijuana cause psychosis in any person or specifically in those at increased risk of psychosis? If the latter, then marijuana—rather than causing new, unanticipated cases—might bring forward schizophrenia onset in individuals who would have developed it later. Thisexplanation is consistent with data showing that persons born in more-recent cohorts seem to have an earlier age of schizophrenia onset.
15
 
Vulnerability for psychosis.
Evidence strongly suggests that marijuana-induced psychotic symptoms are more prevalent amongvulnerable or psychosis-prone individuals.
 
When given 2.5 mg of delta-9-THC, 80% of 13 patients with well-controlled schizophrenia experienced high Positive andNegative Syndrome Scale scores, compared with 35% of 22 healthy controls.
2
 
 
Unusual perceptions or thought influence were more common following marijuana use in all participants in a naturalisticexperiment, but much more so in “at risk” individuals who had previously described isolated psychotic symptoms.
16
 
 
Adolescents and young adults ages 14 to 24 who used marijuana and displayed high “psychoticism” scores at baseline hadmore than twice the risk of a psychosis outcome 4 years later than did those without high scores.
17
 
Schizophrenia onset.
Marijuana users who suffer a drug-induced psychosis are at very high risk of developing a psychotic illness later on.A
3-year follow-up study
18
of 535 patients who had not been treated for psychotic problems before being diagnosed with marijuana-induced psychotic symptoms found that:
 
marijuana-induced psychotic episodes often remitted quickly with minimal treatment
 
about one-half of patients were diagnosed with a schizophrenia-spectrum disorder (mostly paranoid schizophrenia) at followup
 
 
the gap between the marijuana-induced episode and diagnosis of a schizophrenia-spectrum disorder was >1 year in 47% of cases.
 
the first episode of schizophrenia in these patients occurred several years earlier than in schizophrenia patients withoutmarijuana-induced psychosis.Although these findings require replication, they challenge the belief that marijuana-induced psychosis is benign (Box 3).
IMPLICATIONS FOR TREATMENT
Most psychiatric practitioners treat patients who have psychotic illness and use marijuana (Box 4). Compared with nonusers, these patientstend to have:
 
earlier age of schizophrenia onset
 
more psychotic symptoms
 
worse prognosis because of poorer treatment adherence
 
increased symptom severity and persistence
 
higher relapse rates.
19
 Therefore, ask patients with psychotic disorders about their marijuana use, and treat both the marijuana use and the psychosis. Evidence toguide treatment is scarce, however. Nicotine, marijuana, and alcohol use are often intertwined. This suggests that treatments that target avariety of substances may be more efficient than targeted ones, even if the generic interventions are brief.
20
 A study of marijuana users with early psychosis showed, for example, that marijuana-focused treatment was not more effective thanpsychoeducation, although both resulted in reduced use.
21
In nonpsychotic individuals, giving 90 adult patients incentive vouchers toexchange for retail items each time they provided a marijuana-negative urine specimen resulted in increased abstinence rates over a 12-month period (Box 5).
22
,
23
Cognitive-behavioral therapy helped to sustain the vouchers’ positive effect on abstinence after the initial 14-weektreatment.
23
 Treatment with first-generation antipsychotics does not appear to decrease substance use. Several studies suggest that clozapinedecreases the use of nicotine, alcohol, or other substances among patients with schizophrenia,
24
though this does not necessarily apply toother second-generation antipsychotics (Box 6).
IMPLICATIONS FOR PREVENTION
Psychiatric practitioners can play an important role in making young people aware of the mental health risks of using marijuana. Marijuanause fluctuates population-wide, depending in part on public perception of its harmfulness. Its use may diminish, therefore, as information onits mental health hazards percolates into high schools and the community at large. We also have the duty to make policy makers andlegislators aware of this information.
25
 
Related resources
 
National Institute on Drug Abuse.www.marijuana-info.org.
 
Cannabis dependence.www.mentalhealth.com/dis/p20-sb03.html.
 
Castle D, Murray R, eds.
Marijuana and madness: psychiatry and neurobiology.
Cambridge, UK: Cambridge UniversityPress; 2004.
 
Hall W, Pacula RL.
Cannabis use and dependence: public health and public policy.
Cambridge, UK: Cambridge UniversityPress; 2003.
Drug brand names
Clozapine • Clozaril
 

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